Wiki Physical Exam - I have a question about physical examinations

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LLRodgers

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Hello,

I have a question about physical examinations. If the physician states that the physical exam is unchanged from the prior visit. Can I use the prior visit's physical exam to come up with an E/M code.

Some times they indicate that there was no physical exam, due to the patient is just coming in for results of an MRI and they decide what they are going to do (surgery etc)

Not sure how to handle this, any thoughts are very much appreciated.

Thank you,
Linda
 
You may not use a PE from a previous encounter. The only item that may be brought forward is ROS and only if the provider indicates the date and location(such as office note), and that it is reviewed with the patient. The PE is the patient condition at this encounter and cannot be brought forward from the previous note. The provider must examine the patient and must document those findings for each encounter.
 
Thank you for your help, I will educate the doctors on this one. For some reason lately they are dictating "No Change from Previous exam"

Again Thank you!
Linda
 
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